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Can private franchises work for general practice?

Private companies can enhance patient care by treating the customer as king, argues GP Dr James Heath, managing director of Aston Healthcare. But Dr Peter Swinyard warns there is a real risk that privately run franchises will disrupt the doctor-patient relationship.

Private companies can enhance patient care by treating the customer as king, argues GP Dr James Heath, managing director of Aston Healthcare. But Dr Peter Swinyard warns there is a real risk that privately run franchises will disrupt the doctor-patient relationship.

Yes

Even Heart of Birmingham Teaching PCT – for all its reputation as a maverick – must have been taken aback by the level of outrage it provoked when it announced last November its plans to franchise out GP services.

Variously described as ‘arrogant', having ‘lost the plot' and ‘in danger of tearing up general practice in this country', the PCT has quickly assumed pariah status in many quarters.

But is the model it has proposed – and the increasing involvement of the private sector in general practice – really so wrong?

Qualities such as brand values, consistent service delivery and uniformity of customer care are what we at Aston Healthcare have always sought to achieve in all our GP practices – 10 in total across Merseyside and Nottinghamshire – and the main beneficiaries in all this continue to be our patients.

A recurring criticism of plans for GP franchises and the advancement of the private sector is that the prized doctor-patient relationship will be eroded if individual practices consolidate into larger commercial enterprises.

Yet this presupposes that every surgery offers the same high standard of patient access and care. This cosy image is perhaps in need of a revisit.

Our experience as a private company that has acquired a range of different practices, including several which were underachieving, is that the resources and scalability of a commercial organisation can only enhance the quality of patient care delivered within the NHS.

Frustrated by Government legislation, targets and budgets that have transformed the primary care landscape in recent years, the daily workload of the average GP has eroded the time available for the core responsibility of treating patients.

Brand values

An organisation that can come in and centralise the business support and administrative function of a practice will enable the GP to focus once more on patient care.

Furthermore, there is the opportunity through practice-based commissioning to give patients access to a much wider range of services, many traditionally associated with secondary care provision, such as ultrasound scanning, diagnostic services for diseases like osteoporosis and diabetes, and minor surgery.

The negative association of the franchise business model with, for example, fast food outlets, is easy to understand but I have less sympathy with the suggestion that the involvement in franchises of companies such as Virgin, Tesco and Asda would automatically be a bad thing.

These organisations have all demonstrated the very greatest understanding of the ‘consumer as king'.

Brand values, sustainability and consistent quality are the very hallmarks of their business success.

Far from being ‘the end of general practice as we know it in this country', I'd have every faith that, if it ever came to it, these organisations could quickly and efficiently replicate and even enhance the best aspects of the traditional doctor-patient relationship.

Dr James Heath is managing director of Aston Healthcare, a primary care provider based in Merseyside, which was formed in 2003 and manages the care of nearly 40,000 patients. He works as a GP in Liverpool.


No

One of the strengths of general practice is the individuality of practices and the choice that gives to patients.

Some patients prefer the more intimate and friendly surroundings of a smaller practice and want a therapeutic relationship with their own doctor.

Others prefer the more impersonal surroundings of a large surgery, the convenience of seeing one doctor for one thing and one for another (and sometimes playing the one against the other) and the wider facilities such a practice can more easily afford.

The risk of franchising is that all practices will be dragooned into an identity that ill fits them or their patients. This is not inevitable and I believe it is not desirable.

There is very little international experience of the franchising of medical care, still less in franchising parts of primary care (or fractional franchising) and hardly any of franchising primary care in a developed country.

Most of the experience so far is in the developing world. Examples include family planning in Kenya (Kisumu Medical Educational Trust) and Pakistan (Greenstar network) and midwifery in the Phillipines (Well-Family Midwife Clinic Network)1.

The GP contract of 2004 opened the door to franchising of GP services by ending the GP monopoly of provision2, with the separation of the out-of-hours service from core general practice.

Enhanced services have also provided an opportunity for fractional franchising and it is likely that QOF targets will provide a future opportunity for non-GPs to tender for parts of GPs' present core work.

But one of the problems with franchising of medical practice is the incredible range of services we all provide.

What makes it even more complex is the fact that each surgery offers a subtly different blend of service according to the staffing balance and the experience of clinicians – and the facilities they enjoy.

Political windstorms

To have a standard brand, which would allow a surgery to be a recognisable Asda or Virgin surgery, would be an enormous challenge.

While one could perhaps standardise hospital services, there are no measurement methods that could credibly monitor primary care clinics3.

While the QOF has allowed some PCTs to draw up league tables and criticise those who do not shine in this supposedly voluntary part of our contract, the QOF only measures the measurable.

What is more important to patients is not the measurable (and highly valuable) improvement we have made in the control of diabetes, hypertension and so on, but the personal care they receive in the surgery.

The 84% satisfaction rating GPs achieved last year – surely the envy of every politician in the land – is not down to how many tablets of simvastatin were prescribed or how many patients had their blood pressure reduced. It was down to the personal relationship between patients and their own doctor.

One could argue that we are all operating franchises under the NHS brand.

At its best, general practice is innovative and extraordinary in the value it gives for the investment by the state. But not all is well with independent contractor status.

The independence which has allowed innovation in most places has allowed isolationism and poor practice elsewhere.

While it may be a reasonable quality goal for the level of service a patient experiences to be uniform, the reflex answer of exerting control by subsuming practices into a larger organisation, subject to line-management and hierarchy, ill fits the requirements of primary care4.

I do not believe the future of general practice is inevitably bound up with the bigger-is-better philosophy, polyclinics or Asda surgeries.

We do not all have to subsume our well-tried and tested ways of practising to the political windstorms that besiege our practices at present.

Dr Peter Swinyard is honorary secretary of the Family Doctor Association and a GP in Swindon, Wiltshire

heath

Virgin, Tesco and Asda have all demonstrated the very greatest understanding of the ‘consumer as king'.

swinyard

I do not believe the future of general practice is inevitably bound up with the bigger-is-better philosophy.

ASDA boston

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